Postoperative Renal Failure Research Articles

Risk Analysis and Outcomes of Postoperative Renal Failure After Aortic Valve Surgery in the United States

Postoperative renal failure (RF) compromises early outcomes in cardiac surgery. In contrast, long-term survival and progression of RF after aortic valve replacement (AVR) with or without coronary artery bypass graft surgery (CABG) remain undefined. From 2008 through 2015, records of AVR with or without CABG in The Society of Thoracic Surgeons database were linked to Medicare claims data. Postoperative RF was categorized as being with new dialysis (RF-D) or without new dialysis (RF no-D). Cox proportional hazards models were used to conduct a risk analysis and evaluate outcomes in this patient group. Of 164,727 patients undergoing AVR with or without CABG, 3.5% had postoperative RF, of whom 63.3% required dialysis. Operative mortality of postoperative RF was 39.2%, higher for dialysis than for no-dialysis patients (46.1% vs 26.1%, P < .0001). Both RF dialysis patients and no-dialysis patients had a higher early (less than 30-day) mortality risk (hazard ratio [HR] 11.29, P < .0001 and HR 8.03, P < .0001, respectively) compared with no postoperative RF. At a median follow-up of 2.7 years, RF-D and RF no-D remained relevant risk factors, however, with a lower magnitude of effect (HR 2.42, P < .0001, and HR 1.69, P < .0001, respectively). Preoperative glomerular filtration rate (GFR) less than 30 mL · min-1 · 1.73 m-2 had a lower early mortality risk (HR 0.48, P < .0001) but higher late mortality risk (HR 1.5, P < .0001) compared with GFR greater than 60. Predictors for long-term progression to RF-D included preoperative GFR less than 30 (HR 13, P< .0001), GFR 30 to 60 (HR 2.47, P= .006), and insulin-dependent diabetes mellitus (HR 1.96, P= .001). Postoperative RF after AVR with or without CABG was associated with higher early and late mortality, which further increased with a new requirement for dialysis. Once postoperative RF develops, preoperative renal dysfunction does not increase early mortality; however, it predicts late survival. Preoperative renal function is associated with progression of postoperative RF to dialysis.

Increased Glucose Variability Is Associated With Major Adverse Events After Coronary Artery Bypass

Elevated preoperative hemoglobin A1c (HbA1c) is a predictor of poor outcomes after coronary artery bypass grafting (CABG), but the role of postoperative glucose variability (GV) is unknown. We hypothesized that short-term postoperative GV is associated with major adverse events (MAEs) after isolated CABG. This retrospective study evaluated 2215 patients who underwent isolated CABG from January 2012 to March 2018 at 2 medical centers. Postoperative GV in the first 12 hours and 24 hours was measured by the SD, coefficient of variation, and mean amplitude of glycemic excursions. The primary outcome (MAEs) was the composite of postoperative cardiac arrest, pneumonia, renal failure, stroke, sepsis, reoperation, and 30-day mortality. Multivariate logistic regression assessed the independent association of GV with MAE. A total of 2215 patients met the study criteria, and an MAE developed in 260 patients (11.7%). High 12-hour and 24-hour postoperative GV were associated with elevated HbA1c, insulin-dependent diabetes, renal failure, and nonelective operation. Multivariate logistic regression analysis showed MAEs were associated with increased mean postoperative glucose in the first 12 hours (odds ratio [OR], 1.013; 95% confidence interval [CI], 1.008-1.018; P < .001), the first 24 hours (OR, 1.017; 95% CI, 1.010-1.024; P < .001), and 24-hour postoperative GV (OR, 1.22; 95% CI, 1.09-1.37; P < .001). MAEs were not associated with preoperative HbA1c or 12-hour postoperative GV. Increased 24-hour but not 12-hour postoperative GV after CABG is a predictor of poor outcomes. Preoperative HbA1c is not associated with MAEs after adjusting for postoperative mean glucose and GV.

Experience of stent-graft repair in acute ascending aortic syndromes.

Endovascular repair is an alternative to surgical treatment for ascending aortic syndromes for those at high risk. We present our experience of endovascular repair for acute type A aortic dissections and intramural hematomas and discuss the outcomes. From January 2015 to May 2018, six patients diagnosed with acute type A aortic dissections or type A intramural hematoma underwent endovascular procedures in our hospital. The mean age of the patients was 58 ± 16 years, and the median follow-up was 11 months. The entry tear occurred in the ascending aorta in two patients (2 of 6) and the proximal descending aorta in four patients (4 of 6). All of the devices were delivered through the common femoral artery. One was converted to open surgery (1 of 6), one suffered mortality (1 of 6), one had a neurological deficit irrelevant to the procedure, and one had postoperative renal failure. Four patients (4 of 6, 66.7%) had regression of false lumens in the ascending aorta. None of the cases required late reinterventions. We concluded that endovascular repair may be an option for retrograde type A aortic dissections, but it may prove problematic when the entry tear is within the proximal half of the ascending aorta. Rigorous patient selection is crucial, lifelong imaging surveillance is necessary, and improving ascending aorta-specific devices may improve outcomes.

A Meta-Analysis of Randomized and Observational Studies: Aspirin Protects from Cardiac Surgery-Associated Acute Kidney Injury.

Antiplatelet therapy is critical in the management of coronary artery diseases. For patients undergoing cardiac surgeries, including coronary artery bypass graft (CABG) and valve replacement, controversy remains in preoperative antiplatelet therapy concerning risk of bleeding. For safety concern, aspirin is recommended to be withdrawn 5 to 10 days before a cardiac surgery. Recent studies, however, indicate that preoperative aspirin may have a protective effect on cardiac surgery-associated acute kidney injury (CSA-AKI). To estimate the efficacy of preoperative aspirin in preventing CSA-AKI. Eligible studies included randomized controlled trials (RCTs) and observational studies (OSs) of patients, who had undergone CABG, valve replacement, or combined surgery. These studies compared preoperative aspirin with placebo/no aspirin and reported the least incidence of CSA-AKI. One RCT and five OSs met the inclusion criteria. Data retrieved suggested that aspirin prescribed within five days before cardiac surgery decreased post-operative renal failure [odds ratio (OR), 0.67; 95% confidence interval (CI), 0.50-0.89; P < 0.01] and 30-day mortality (OR, 0.64; 95% CI, 0.53-0.77; P < 0.01). One RCT and three OSs suggested aspirin protected from major adverse cardiocerebral events (MACE) (OR, 0.88; 95% CI, 0.76-1.01; P = 0.07). One RCT and two OSs suggested aspirin did not increase risk of re-exploration for bleeding (OR, 1.01; 95% CI, 0.76-1.34; P = 0.95). Preoperative low-dose aspirin decreases post-operative CSA-AKI, mortality, and MACE without increasing the risk of re-exploration. But most of the studies are observational. They lack a uniformed standard on prescription of aspirin and outcomes measurement. No stratification analysis is performed concerning different types of surgical procedures and comorbidities. More randomized controlled trials are necessary to confirm the efficacy and safety of preoperative aspirin prescription.

Current status of cardiovascular surgery in Japan, 2015 and 2016: analysis of data from Japan Cardiovascular Surgery Database. 4-Thoracic aortic surgery.

Thoracic and thoracoabdominal aortic diseases are treated using operative procedures like open aortic repair (OAR), thoracic endovascular aortic repair (TEVAR), or hybrid aortic repair (HAR), or a combination of OAR and TEVAR. The surgical approach to aortic repair has evolved over the decades. The purpose of this study was to examine the current trends in treatment. We extracted nationwide data of aortic repair procedures performed in 2015 and 2016 from the Japan Cardiovascular Surgery Database (JCVSD). In addition to estimating the number of cases, we also reviewed the respective operative mortalities and associated major morbidities (e.g., stroke, spinal cord insufficiency, and renal failure) according to disease pathology (e.g., acute dissection, chronic dissection, ruptured aneurysm, and unruptured aneurysm), site of operative repair (i.e., aortic root, ascending aorta, aortic root to arch, aortic arch, descending aorta, and thoracoabdominal aorta), and the preferred surgical approach (i.e., OAR, HAR, or TEVAR). The total number of cases studied was 35,427, with an overall operative mortality rate of 7.3%. Among the 3 procedures, 64% of patients were treated with OAR. Compared to the data from our previous report (also derived from the JCVSD in 2013 and 2014), the total number of cases and number of OAR, HAR, and TEVAR procedures have increased by 17.0%, 2.4%, 126.1%, and 34.9%, respectively. While the overall stroke rates following aortic arch surgical repair with HAR, OAR, and TEVAR were 10.1%, 8.4%, and 7.3%, respectively, OAR was found to have the lowest stroke rate when limited to cases presenting with a non-dissected/unruptured aorta. The incidence rates of paraplegia following descending/thoracoabdominal aortic surgical repair using HAR, OAR, and TEVAR were 6.3%/10.4%, 4.3%/8.9%, and 3.4%/4.6%, respectively. TEVAR was found to be associated with the lowest incidence of postoperative renal failure. The number of operations for thoracic and thoracoabdominal aortic diseases has increased, though the rate of operations using an OAR approach has decreased. While TEVAR showed the lowest mortality and morbidity rates, OAR demonstrated the lowest postoperative stroke rate for non-dissecting aortic arch aneurysms.

Predictors of operative mortality among cardiac surgery patients with prolonged ventilation.

Prolonged ventilation after cardiac surgery affects survival and increases morbidity. Previous studies have focused on predicting this complication preoperatively; however, indicators of poor outcome in those requiring prolonged ventilation remain ill-defined. We sought to identify predictors of operative mortality in cardiac surgery patients who experience prolonged mechanical ventilation. 1698 patients who underwent cardiac surgery (CAB, aortic valve replacement ± CAB, or mitral valve repair/replacement ± CAB) required prolonged postoperative mechanical ventilation (>24 hours) between 2012 to 2016 in a statewide consortium. Perioperative factors were evaluated to identify the association with operative mortality. Covariates were selected through bootstrap aggregation to fit multivariable logistic regression models. The relative strength of association was determined by the Wald chi-square statistic. Median patient age was 68 years [IQR 61 to 76], 38% (644/1,698) were female, median duration of mechanical ventilation was 65 hours [IQR 38 to 143], median STS predicted risk of mortality was 3.1% [IQR 1.4 to 6.9%], and 15.7% (266/1698) suffered operative mortality. Among preoperative and operative characteristics, patient age and intraoperative initiation of extracorporeal membrane oxygenation (ECMO) were the strongest correlates of operative mortality on the multivariate analysis. Among postoperative factors, cardiac arrest and renal failure requiring dialysis were the strongest predictors of risk-adjusted operative mortality. Type of operation or surgical center had no association to mortality after risk adjustment. Prolonged ventilation following cardiac surgery is associated with a five-fold increase in operative mortality. In these patients, operative mortality is associated with older age, intraoperative initiation of ECMO, postoperative cardiac arrest, and renal failure requiring dialysis.

Is there really a benefit of using minimized cardiopulmonary bypass in CABG? A retrospective propensity score-matched study with 5000 cases.

The concept of minimized cardiopulmonary bypass targets at reduction of adverse effects triggered by extracorporeal circulation. In this study, benefits of minimized bypass in CABG were evaluated under particular consideration of patient body mass index and surgeon impact. From 2004 to 2014, 5164 patients underwent coronary bypass surgery (CABG). Conventional cardiopulmonary bypass (CCPB) was used in 2376 patients, minimized cardiopulmonary bypass (MCPB) in 2788 cases. Multivariate regression models were used in the entire cohort and in a propensity score-matched subgroup after expert CABG to figure out clinical differences such as mortality, postoperative renal function, and thromboembolic events. Overall mortality was 1.5% (n = 41) in the MCPB group and 3.5% (n = 82) in CCPB patients (p < 0.001). Postoperative renal failure and hemodialysis occurred in 2.6% (n = 72/MCPB) vs. 5.3% (n = 122/CCPB (p < 0.001). Multivariable regression revealed use of CCPB as risk factor for increased mortality (OR 2.01, p = 0.001), renal failure (OR 1.79, p < 0.001), and myocardial infarction (OR 1.98, p < 0.001) comparable to risk factors such as preoperative ventilation (OR 2.26, p = 0.048), diabetes mellitus (OR 1.68, p = 0.001), and cardiogenic shock (OR 3.81, p = 0.002). Body mass index had no effect on the analyzed outcome parameters (OR 0.92, p = 0.002). Propensity score-matching analysis of an expert CABG subgroup revealed CCPB as risk factor for mortality (OR 2.26, p = 0.004) and postoperative hemodialysis (OR 1.74, p = 0.017). Compared to conventional circuits, minimized bypass use in CABG is associated with lower mortality and less postoperative renal failure. A high body mass index is feasible and not a risk factor for MCPB surgery.

Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study

The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA). This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan–Meier estimator and multivariable Cox regression. There were 140 patients (age [mean ± SD] 74.1 ± 8.8 years; 56% men; aneurysm size 64.8 ± 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0–132 months). The Kaplan–Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00–1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.19–4.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15–3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20–8.81; p = .001), stroke (HR 2.63; 95% CI 1.37–5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69–25.35; p = .001) were all associated with mortality. This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.

Factors Associated With Increased Mortality After Isolated Abdominal Aortic Dissection Repair

Postoperative mortality after open and endovascular repair of thoracic aortic dissection (AD) has been the focus of previous research. However, a little has been published on the far less common isolated abdominal aortic dissection (IAAD). The aim of our study was to identify risk factors associated with 30-day postoperative mortality in patients with IAAD. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was queried for patients who underwent open or endovascular AD repair from January 2010 to December 2015. Information regarding patient demographics, comorbidities, preoperative laboratory values, procedure details, and postoperative complications were analyzed, and predictors of 30-day mortality were identified. Risk stratification by the type of aortic repair and surgery setting was performed, and patient characteristics associated with mortality in each setting were determined. We employed chi-squared test, Student's t-test, and Mann-Whitney U test for the univariate analysis, while the multivariate analysis was performed using a stepwise binary logistic regression test. There were 229 patients who met the specified criteria, 15 died within 30days postoperatively, and 214 survived beyond the same period (mortality rate was 6.5%). Among preoperative factors, a history of chronic obstructive pulmonary disease (COPD), preoperative ventilator dependence, preoperative transfusion of ≥1 unit packed RBCs, emergent operation, and advanced American Society of Anesthesiologists (ASA) class were associated with increased risk of mortality. Postoperative complications associated with a higher risk of mortality were acute kidney injury, mechanical ventilation ≥48hours, unplanned intubation, myocardial infarction, septic shock, and blood transfusion. On multivariate analysis, risk factors independently associated with increased risk of mortality were a history of COPD (adjusted odds ratio [AOR], 10.5; P=0.013), postoperative acute renal failure (AOR, 12.8; P=0.003) and septic shock (AOR, 15.3; P=0.014). Multiple preoperative and postoperative factors are associated with a high risk of death after IAAD repair. A better control of COPD and prevention of postoperative acute renal failure and septic shock may result in better outcomes.

PB2257 USE OF ARGATROBAN AS AN ANTICOAGULANT TREATMENT ALTERNATIVE IN CRITICAL PATIENTS WITH HEPARIN‐INDUCED THROMBOCYTOPENIA. EXPERIENCE IN A THIRD LEVEL HOSPITAL.

Background:Heparin is a widely used drug. The most frequent complication derived from its use is the haemorrhage. However, an uncommon but potentially serious adverse effect is heparin‐induced thrombocytopenia (HIT). The goal of treatment of HIT is to reduce platelet activation and thrombin formation to decrease the risk of thrombosis. Argatroban is the drug of choice in HIT patients as an alternative anticoagulant treatment in critically ill patients with high risk of haemorrhage, postoperative cardiac events or renal failure, since it allows close control of anticoagulation.Aims:To analyze the clinical, laboratory and therapeutic characteristics of patients treated with Argatroban by HIT in our hospitalMethods:Retrospective analysis or patients treated with Argatroban for diagnosed HIT during the last year.Results:Four patients have required treatment with Argatroban for HIT since they required maintenance of anticoagulation due to mitral prosthesis, unstable angina, DVT in the right lower extremity and acute ischemia in the left lower extremity. Median age 68 years (43‐79). All of them were diagnosed with HIT according to the 4T score during their admission to the Intensive Care Unit. PF4/Heparin antibody testing was positive in the four patients.The median number of days from the start of Heparin treatment (2 with unfractioned and 2 with low molecular weight) to the onset of thrombocytopenia was 6 days (1‐8). Median platelets at diagnosis were 73x109/L (49‐82). Median number of days from the start of Argatroban to platelet recovery was 6 days (3‐12). Median number of days of treatment with Argatroban was 9.5 days (2‐18). Argatroban dose was adjusted to maintain aPTT at 1.5‐3.0 times baseline. 3 patients presented thrombotic events, 2 directly related to HIT (1 ischemic stroke and 1 acute ischemia of right upper extremity) and 1 with worsening of reperfusion of the limb. 2 patients required amputation of the limb. No adverse events associated with Argatroban, including haemorrhage, were observed.Summary/Conclusion:HIT is a potentially catastrophic complication of heparin treatment which requires urgent detection and treatment with a non‐heparin anticoagulant such as Argatroban should be initiated. Even in critically ill patients, Argatroban anticoagulation improves clinical outcomes in patients who have HIT, without increasing bleeding risk.

Acute kidney injury during daptomycin versus vancomycin treatment in cardiovascular critically ill patients: a propensity score matched analysis

BackgroundGram-positive organisms are a leading cause of infection in cardiovascular surgery. Furthermore, these patients have a high risk of developing postoperative renal failure in intensive care unit (ICU). Some antibiotic drugs are known to impair renal function. The aim of the study was to evaluate whether patients treated for Gram-positive cardiovascular infection with daptomycin (DAP) experienced a lower incidence of acute kidney injury (AKI) when compared to patients treated with vancomycin (VAN), with comparable efficacy.MethodsICU patients who received either DAP or VAN, prior to or after cardiovascular surgery or mechanical circulatory support, from January 2010 to December 2012, were included in this observational retrospective cohort study. We excluded patients with end stage renal disease and antibiotic prophylaxis. The primary endpoint was the incidence of AKI within the first week of treatment. Secondary endpoints were the incidence of AKI within the first 14 days of treatment, the severity of AKI including renal replacement therapy (RRT), the rates of clinical failure (unsuccessful infection treatment) and of premature discontinuation and mortality. To minimize selection bias, we used a propensity score to compare the 2 groups. Univariate and multivariate analysis were performed to determine factors associated with AKI.ResultsSeventy two patients, treated for infective endocarditis, cardiovascular foreign body infection, or surgical site infection were included (DAP, n = 28 and VAN, n = 44). AKI at day 7 was observed in 28 (64%) versus 6 (21%) of the VAN and DAP patients, respectively (p = 0.001). In the multivariate analysis adjusted to the propensity score, vancomycin treatment was the only factor associated with AKI (Odds Ratio 4.42; 95% CI: 1.39–15.34; p = 0.014). RRT was required for 2 (7%) DAP patients and 13 (30%) VAN patients, p = 0.035. Premature discontinuation and clinical failure occurred more frequently in VAN group than in DAP group (25% versus 4%, p = 0.022 and 42% versus 12%, respectively, p = 0.027).ConclusionsDaptomycin appears to be safer than vancomycin in terms of AKI risk in ICU patients treated for cardiovascular procedure-related infection. Daptomycin could be considered as a first line treatment to prevent AKI in high-risk patients.

Off-pump versus on-pump redo coronary artery bypass grafting: A propensity score analysis of long-term follow-up

ObjectiveRedo coronary artery bypass grafting (CABG) is associated with an increased early mortality reported up to 16%. The aim of this study was to analyze the early and long-term results after redo CABG with special focus on the feasibility and safety of the off-pump technique in the setting of a high-volume off-pump CABG center. MethodsFrom January 2006 to June 2015, isolated redo CABG was performed in 304 patients (179 = on-pump redo CABG, 125 = off-pump redo CABG). We used propensity score matching with 14 preoperative variables to adjust for differences in baseline characteristics between the on-pump redo CABG and the off-pump redo CABG groups. After 1:1 matching we selected 108 pairs for each group. Mean follow-up rate was 4.01 years. ResultsThe final sample was 83.9% men (n = 225) with a mean age of 69.77 ± 8 years. After propensity score matching there was a significant difference in the total number of grafts performed in favor of on-pump redo CABG (P = .011), whereas 66.7% (72 out of 108) of off-pump redo CABG patients received total arterial grafts. Off-pump redo CABG patients had a lower rate of postoperative renal failure necessitating dialysis (4.6% vs 0%; P = .06), required less recovery time in the intensive care unit (1.33 ± 1.03 days vs 4.4 ± 7.98 days; P < .001) and were discharged more quickly (10.08 ± 5.35 days vs 14.1 ± 10.6 days; P = .001). Off-pump redo CABG led to better long-term survival (log-rank test, P = .086). ConclusionsIn our study, patients undergoing off-pump redo CABG had fewer postoperative complications, achieved faster recovery, and had better long-term survival. Hence, off-pump redo CABG is safe and feasible.

Outcome Prediction after Surgical Management of Prosthetic Mitral Valve Dysfunction; a single center experience

Background: Prosthetic Mitral valve dysfunction is a serious complication associated with a high mortality rate particularly in obstructive cases. The number of cases undergoing redo mitral valve surgery is increasing. This study aims to identify the risk factors of mortality and morbidity in patients who underwent redo mitral valve surgery for prosthetic mitral valve dysfunction.&#x0D; &#x0D; Methods: This study was conducted on 80 patients who underwent re-operation for management of prosthetic mitral valve dysfunction from December 2014 to February 2018. Patients’ age ranged between 21 and 58 years with a mean of 36.8±9.60 years, and 53 patients (66.3%) were males. The causes of mitral valve malfunction were thrombus in 67 patients (83.7%) and pannus in 13 patients (16.3%).&#x0D; Results: 53 patients (66.25%) had urgent surgical intervention. Thrombectomy or pannus resection was done in 75 patients (93.75%) and valve replacement in 5 patients (6.25%). Re-exploration was required in 11 patients (13.75%) and was significantly associated with diabetes (p= 0.004), preoperative liver dysfunction (p= 0.04), elevated INR (p= 0.006), trial of thrombolysis (p&lt;0.001) and prolonged ischemic time (p= 0.01). Postoperative renal failure occurred in 11 patients (13.75%) and was associated with diabetes (p&lt; 0.001), preoperative renal dysfunction (p&lt; 0.001), prolonged cardiopulmonary bypass and ischemic times (p&lt; 0.001). 17 patients (21%) required prolonged mechanical ventilation and it was significantly associated with chronic obstructive lung disease (p&lt; 0.001), pulmonary edema (p &lt;0.001), low systolic blood pressure (p &lt;0.001), low ejection fraction (p&lt;0.001) and thrombectomy (p&lt;0.001). Operative mortality occurred in 13 patients (16%) and was significantly associated with preoperative stroke, renal dysfunction, low blood pressure and acute pulmonary edema (p &lt;0.001).&#x0D; Conclusion: Reoperation for prosthetic mitral valve dysfunction is associated with high morbidity and mortality. Outcomes can be predicted based on preoperative clinical status and operative times. Thrombectomy and pannus resection with the repair of the paravalvular leak is a simple and easy technique for management of those patients with a reduction of cardiopulmonary bypass and cross-clamp times.

Distal Extended Endovascular Aortic Repair PETTICOAT: A Modified Technique to Improve False Lumen Remodeling in Acute Type B Aortic Dissection

Data from the literature suggest that in patients with acute, complicated type B aortic dissection (cTBAD), initial successful treatment with thoracic endovascular aneurysm repair (TEVAR) is not necessarily associated with favorable remodeling of the dissected aorta during follow-up, and long-term results indicate that TEVAR failed to completely suppress false lumen patency. Sealing of all relevant distal reentries, infrarenal and/or iliac, seems to be the key issue to induce total false lumen thrombosis in abdominal aorta as well as the iliac arteries, especially in complicated patients presenting with malperfusion or complete true lumen collapse. Of the 34 consecutive patients diagnosed with cTBAD at our hospital from January 2015 to April 2018, 30 had complicated dissections receiving endovascular treatment according to the standard Provisional ExTension To Induce COmplete ATtachment (PETTICOAT) technique and were excluded from this study, whereas 4 patients with radiologic evidence of multiple reentry tears at detached lumbar arteries and iliac bifurcation with complete true lumen collapse and clinical evidence of malperfusion were treated with a modified PETTICOAT technique with distal extension of the aortic stent, balloon expansion of the stented true lumen, and use of the AFX bifurcated endograft system to preserve the natural aortic bifurcation and provide complete distal sealing of reentry tears. Primary technical success was achieved in all patients. No postoperative deaths were observed, but 1 patient experienced an hemorrhagic shock on the second postoperative day. No patient suffered postoperative stroke, paraplegia, paraparesis, or acute renal failure. Using an abdominal aortic bifurcated endograft with PETTICOAT to treat acute cTBAD seems to be a feasible approach in high-risk patients to improve aortic remodeling. The AFX bifurcated endograft system meets the requirements of anatomical fixation and sealing of distal tears.

Retrograde Inferior Vena caval Perfusion for Total Aortic arch Replacement Surgery (RIVP-TARS): study protocol for a multicenter, randomized controlled trial

BackgroundDuring total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, the organs in the lower body, such as the viscera and spinal cord, are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood.MethodsThis study is designed as a multicenter, computer-generated, randomized controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS. A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, which will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, which will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. All patients will be analyzed according to the intention-to-treat protocol.DiscussionThis study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS.Trial registrationClinicaltrials.gov, ID: NCT03607786. Registered on 30 July 2018.

Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study

The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA). This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan-Meier estimator and multivariable Cox regression. There were 140 patients (age [mean±SD] 74.1±8.8 years; 56% men; aneurysm size 64.8±19mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n=20; 14.7%) was the most common complication, followed by paraplegia (n=13; 9.6%) and major bleeding (n=13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n=31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0-132 months). The Kaplan-Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00-1.07; p=.046), history of stroke (HR 2.35; 95% CI 1.19-4.63; p=.014), previous aortic surgery (HR 2.11; 95% CI 1.15-3.87; p=.016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20-8.81; p=.001), stroke (HR 2.63; 95% CI 1.37-5.03; p=.004), and renal failure (HR 8.25; 95% CI 2.69-25.35; p=.001) were all associated with mortality. This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.

Contemporary Outcomes in Patients with Cardiac Amyloidosis Undergoing Heart Transplantation

Purpose Cardiac amyloidosis causes significant morbidity and mortality, leading to restrictive cardiomyopathy, heart failure, and death. Many patients are diagnosed late when irreversible amyloid fibril deposition has occurred. Heart transplantation may be considered in such patients. Historically, heart transplant outcomes were worse in cardiac amyloid patients compared with other types of heart failure, in part due to the systemic nature of the disease. However, effective therapies, particularly for light chain (AL) amyloidosis, have emerged, and disease remission is now possible. We aimed to assess whether transplant outcomes for cardiac amyloidosis are better in the contemporary era. Methods We studied cardiac amyloid patients seen during 2004-2017 at the Stanford University and Kaiser Permanente Santa Clara medical centers who underwent heart transplantation. We examined pre-transplant characteristics and post-transplant outcomes in this group compared with the overall transplant population at our centers. Results During the study period, 31 patients (13 with AL amyloidosis and 18 with transthyretin (ATTR) amyloidosis) underwent heart transplantation. ATTR patients were older, more likely to be male, had worse baseline renal function, and had longer waitlist times compared with AL patients and the overall transplant population. Post-transplant, there were no differences in post-operative bleeding, renal failure, infection, rejection, or malignancy. There was no significant difference in the overall survival between cardiac amyloid patients and the overall population (median follow up: 1462 days; Figure 1). Conclusion This single-center, retrospective study reports detailed, long-term heart transplantation outcomes in a large cohort of cardiac amyloid patients. In carefully selected patients with cardiac amyloidosis, heart transplantation can be an effective therapeutic option with outcomes similar to those transplanted for other causes of heart failure.

Comparison of ECMO Patients Bridged to LVAD vs Bridged to Transplantation

Purpose With the implementation of the new heart allocation system, the goal of our study was to compare the outcomes of patients supported with extracorporeal membrane oxygenation who were bridged to transplantation versus bridged to a left ventricular assist device prior to transplantation. Methods The UNOS database was queried for all adult patients (age >=18) who required support with ECMO at the time of listing or while on the waitlist for a heart from 2001-2018. Patients who successfully underwent orthotopic heart transplantation were stratified into those bridged immediately to transplantation from ECMO and those bridged to an LVAD prior to transplantation. Demographics, one year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared. Results A total of 186 patients meeting criteria were identified. 117 patients were bridged from ECMO directly to transplantation, and 69 patients were successfully bridged from ECMO to either a Heartmate II or Heartware device prior to transplantation. Kaplan-Meier survival estimates and log-rank test found a statistically significant difference in one year survival between patients who were bridge from ECMO to transplantation compared to those who were bridged to an LVAD prior to subsequent transplantation (p=0.0004, Figure 1). Incidence of new postoperative renal failure requiring dialysis (20.4% vs 1.5%), stroke (10.4% vs 1.5%), and postoperative graft failure (14.0% vs 2.9%) was higher and episodes of rejection requiring treatment (12.6% vs 18.8%) were lower in the patients bridged directly from ECMO to transplantation compared to patients bridged to an LVAD prior to transplantation. Conclusion Our study suggests that bridging ECMO patients to an LVAD prior to transplantation will result in improved one year survival compared to patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies.

Risk factors and outcomes for bowel ischemia after open and endovascular abdominal aortic aneurysm repair

ObjectiveBowel ischemia (BI) is a serious complication after abdominal aortic aneurysm (AAA) repair. We sought to identify the incidence and risk factors associated with the development of postoperative BI and the post-BI outcomes for patients undergoing open aortic repair (OAR) and endovascular aortic repair (EVAR) of AAAs. MethodsA retrospective analysis was conducted for all patients who had undergone OAR or EVAR from 2003 to 2017 using the Vascular Quality Initiative database. Univariate (Student's t test, χ2, median) and multivariable (logistic regression) analyses were used to identify independent factors associated with postoperative BI and compare the post-BI in-hospital outcomes and mortality. ResultsWe identified 45,474 patients who had undergone infrarenal AAA repair (OAR, 21.5%; EVAR, 78.5%). The overall incidence of postoperative BI was 1.9% (OAR, 6.2% vs EVAR, 0.8%; P < .001). OAR was associated with a threefold increased odds of BI compared with EVAR (adjusted odds ratio [aOR], 3.24; 95% confidence interval [CI], 2.49-4.22; P < .001). The independent factors associated with BI after OAR included older age (aOR per year of age, 1.02; 95% CI, 1.00-1.03), congestive heart failure (aOR, 1.44; 95% CI, 1.05-1.98), and ruptured aneurysm (aOR, 4.16; 95% CI, 2.98-5.81; P < .01 for all). We also found that transfusion ≥1 U (aOR, 1.69; 95% CI, 1.30-2.20), a transperitoneal approach (aOR, 2.13; 95% CI, 1.03-1.87), supraceliac clamping (aOR, 1.58; 95% CI, 1.08-2.33), and inferior mesenteric artery reimplantation (aOR, 1.41; 95% CI, 1.06-1.89) were associated with greater odds of BI after OAR (P < .01 for all). Similarly, we found that ruptured aneurysms, a longer operative time, and transfusion of ≥1 U of blood were associated with BI after EVAR (P < .001 for all). For both OAR and EVAR, the postoperative stay (median, 13 days [interquartile range (IQR), 7-26 days] vs 7 days [IQR, 5-10 days] and 11 days [IQR, 4-23 days] vs 1 day [IQR, 1-3 days], respectively) and 30-day mortality (35.0% vs 6.4% and 40.5% vs 1.9%, respectively) were significantly higher for patients with BI (P < .001 for all). The predictors of mortality for patients with BI were surgical management (aOR, 2.05; 95% CI, 1.28-3.30), older age (aOR, 1.05; 95% CI, 1.02-1.07), symptomatic aneurysm (aOR, 1.26; 95% CI, [0.60-2.62), ruptured aneurysm (aOR, 2.23; 95% CI, 1.43-3.48), longer operative time (aOR, 1.11; 95% CI, 1.01-1.22), and postoperative renal complications (aOR, 2.98; 95% CI, 1.80-4.96; P < .05 for all). ConclusionsConfirming the results from previous studies, we found that BI is more common after a ruptured aneurysm and OAR. Other associated intraoperative factors included a transperitoneal approach, supraceliac clamping, and a reimplanted inferior mesenteric artery. More than one third of patients who developed postoperative BI in our cohort had died within 30 days after AAA repair. The factors associated with mortality after BI included surgical management and postoperative renal failure. A high index of suspicion for the signs and symptoms of BI should be maintained postoperatively for patients presenting with the risk factors identified.

Management of duodenal trauma: A retrospective review from the Panamerican Trauma Society.

The operative management of duodenal trauma remains controversial. Our hypothesis is that a simplified operative approach could lead to better outcomes. We conducted an international multicenter study, involving 13 centers. We performed a retrospective review from January 2007 to December of 2016. Data on demographics, mechanism of trauma, blood loss, operative time, and associated injured organs were collected. Outcomes included postoperative intra-abdominal sepsis, leak, need for unplanned surgery, length of stay, renal failure, and mortality. We used the Research Electronic Data Capture tool to store the data. Poisson regression using a backward selection method was used to identify independent predictors of mortality. We collected data of 372 patients with duodenal injuries. Although the duodenal trauma was complex (median Injury Severity Score [ISS], 18 [interquartile range, 2-3]; Abbreviated Injury Scale, 3.5 [3-4]; American Association for the Surgery of Trauma grade, 3 [2-3]), primary repair alone was the most common type of operative management (80%, n = 299). Overall mortality was 24%. On univariate analysis, mortality was associated with male gender, lower admission systolic blood pressure, need for transfusion before operative repair, higher intraoperative blood loss, longer operative time, renal failure requiring renal replacement therapy, higher ISS, and associated pancreatic injury. Poisson regression showed higher ISS, associated pancreatic injury, postoperative renal failure requiring renal replacement therapy, the need for preoperative transfusion, and male gender remained significant predictors of mortality. Duodenal suture line leak was statistically significantly lower, and patients had primary repair over every American Association for the Surgery of Trauma grade of injury. The need for transfusion prior to the operating room, associated pancreatic injuries, and postoperative renal failure are predictors of mortality for patients with duodenal injuries. Primary repair alone is a common and safe operative repair even for complex injuries when feasible. Therapeutic study, level IV.